108 APT#B12 Notification of Deleading 1999 sob
Department of Public Health/Department Of Labor 11 Industries
NOTIFICATION OF DELEADING WORK FILE NUMBER
ALL sections of this for nest be completed in order to comply with
the notification requirements of M.G.L.C. 111 § 197,
454 CM 22.00 and 105 CMR 460.000 as most recently amended
Contractor performing ^project \��\NN ,v License#�\y Exp. Date\-a.`S-OQ)
Lead Paint Inspector Awn? hwe-St License i Nala‘k
PROPERTY OWNER (If owner or unlicensed owner's agent will be performing low-
risk deleading work,
complete the following ):
Property Owner Agent(s)
Address NOV-2-24.99
Telephone Number
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead
Poisoning Prevention and Control Regulations, 105 Cia 460.175, for owner/agent Low-risk abate ant and
containment. 1 further certify that 1 or ay agent witL be performing the +-following tow-risk activities (1
have circled all that apply):
applying liquid encapsulent capping baseboards removing doors, cabinet doors, shutters
applying exterior vinyl siding covering surfaces
I certify that all the information contained in this
knowledge and belief.
ication is true and correct to the best of my
Date: Signed:
ADDRESS OP PROJECT[ \\ , Q�
Street Address \�
Apt. Number
IVhC\St ��On zip Ct\ct
PropertyOwner }�\ ��p Address a-t- C \-\A\ ,W`,
Telephone Number
���-lea - aa5a
Deleading Method: Wet/Dry Scraping
Demolition
Heat Gun
Caustics
Other
No "\o..\ ,‘\l.A
Liquid Encapsulant
Replacement
If "Other" selected, please explain
Check one: dwelling is multi-family Y single-family
other
Page 2 of 2
Start Date \\- 74.S\- CVQ1 Completion date \\ -aC-1Zkq
When will work be done: am1t c pn4AC{Specify times on site) Weekends? \lp
Project Supervisor NameVNEVAVN NAT)
License/ \4h1 Exp. Date\ -GG
Workman's Compensation Policy\\Number C—Sti eY1c%1t \Q Carrier
>,J
In Case of Emergency Contact: *dv\�. .y (Contractor's Representative)
-:\b1t,
In accordance with Massachusetts General Laws C. 111 4197, 454 CMR 22.00 and 105 OM 460.000, notice of the
date and methad(s) of removal or covering of paint, plaster or other accessible materials containing
dangerous levels of lead is to be provided and net be received by the following persons, at least ten
business days prior to the beginning of deleading. NOTIFICATIONS MAY BE FAXED.
1. Department of Labor 6 Industries, Division of Asbestos and Lead Enforcement
100 Cartridge Street, Roam 1106, Boston, MA 02202 FAX: (617)727-7568
2. Director, Childhood Lead Poisoning Prevention Program1 5� - Q,y\CZI/
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130 FAX: (617) 96 •6931
(617) 522-8735
3. Occupants of dwelling unit
4. All other occupants of the residential premises, if any
5. Local Board of Health/Code Enforcement Agency -
6. Massachusetts Historical Commission (if premises are listed on the State Register of Historic
220 Morrissey Blvd. Places, this notification mat be fade upon receipt of an
Boston, MA 02202 Order To Correct Violations or at least 30 days prior to
FAX: (617)727.5128 Initiating preventive deleading)
DELEADINO CONTRACTOR:
The undersigned hereby states, under the pains and penalties of perjury, that
he/she has read and understood the Commonwealth of Massachusetts Deleading
regulations, 454 CNR 22.00, antl-lead Poisoning Prevention and Control
Regulations, 105 CNA 460.000, and that the information contained in this
notification is true and correct to the best of his/her knowledge and belief.
Date \lo.4e-te C \\n \‘‘k44 Signed *1a4 `/ t".
Company Name: \e`ev\S. C. - Ne&
Address:
.� c nc�1�0a�A cs� \\'` c4.
Telephone Telephone Number: Si\cam-�a-1- \\Drti:.
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED -
INCOMPLETE NOTIFICATIONS WILL NOT SE ACCEPTED AND WILL HE RETURNED BY D.L.I.